Grays Anatomy for Students 4th Edition

Richard L. Drake
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 ANATOMY
GRAY’S
FOR STUDENTS
Fourth Edition
Richard L. Drake, PhD, FAAA
Director of Anatomy
Professor of Surgery
Cleveland Clinic Lerner College of Medicine
Case Western Reserve University
Cleveland, Ohio

A. Wayne Vogl, PhD, FAAA

Professor of Anatomy and Cell Biology
Department of Cellular and Physiological Sciences
Faculty of Medicine
University of British Columbia
Vancouver, British Columbia, Canada

Adam W. M. Mitchell, MB BS, FRCS, FRCR

Consultant Radiologist
Director of Radiology
Fortius Clinic
London, United Kingdom

Illustrations by
Richard Tibbitts and Paul Richardson

Photographs by
Ansell Horn
GRAY’S ANATOMY FOR STUDENTS, FOURTH EDITION ISBN: 978-0-323-39304-1
IE ISBN: 978-0-323-61104-6

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 The Body
What is anatomy?
Anatomy includes those structures that can be seen grossly
(without the aid of magnification) and microscopically
(with the aid of magnification). Typically, when used by
itself, the term anatomy tends to mean gross or macroscopic
anatomy—that is, the study of structures that can be seen
without using a microscopic. Microscopic anatomy, also
called histology, is the study of cells and tissues using a
microscope.
Anatomy forms the basis for the practice of medicine.
Anatomy leads the physician toward an understanding of
a patient’s disease, whether he or she is carrying out a
physical examination or using the most advanced imaging
techniques. Anatomy is also important for dentists, chiro-
practors, physical therapists, and all others involved in any
aspect of patient treatment that begins with an analysis of
clinical signs. The ability to interpret a clinical observation
correctly is therefore the endpoint of a sound anatomical
understanding.
Observation and visualization are the primary tech-
niques a student should use to learn anatomy. Anatomy is
much more than just memorization of lists of names.
Although the language of anatomy is important, the
network of information needed to visualize the position of
physical structures in a patient goes far beyond simple
memorization. Knowing the names of the various branches
of the external carotid artery is not the same as being able
to visualize the course of the lingual artery from its origin
in the neck to its termination in the tongue. Similarly,
understanding the organization of the soft palate, how it is
related to the oral and nasal cavities, and how it moves
during swallowing is very different from being able to recite
the names of its individual muscles and nerves. An under-
standing of anatomy requires an understanding of the
context in which the terminology can be remembered.
How can gross anatomy be studied?
The term anatomy is derived from the Greek word temnein,
meaning “to cut.” Clearly, therefore, the study of anatomy
is linked, at its root, to dissection, although dissection of
cadavers by students is now augmented, or even in some
cases replaced, by viewing prosected (previously dissected)
material and plastic models, or using computer teaching
modules and other learning aids.
Anatomy can be studied following either a regional or a
systemic approach.
■ With a regional approach, each region of the body
2 is studied separately and all aspects of that region
are studied at the same time. For example, if the thorax
is to be studied, all of its structures are examined.
This includes the vasculature, the nerves, the bones,
the muscles, and all other structures and organs
located in the region of the body defined as the
thorax. After studying this region, the other regions of
the body (i.e., the abdomen, pelvis, lower limb, upper
limb, back, head, and neck) are studied in a similar
fashion.
■ In contrast, in a systemic approach, each system of
the body is studied and followed throughout the entire
body. For example, a study of the cardiovascular system
looks at the heart and all of the blood vessels in the body.
When this is completed, the nervous system (brain,
spinal cord, and all the nerves) might be examined in
detail. This approach continues for the whole body until
every system, including the nervous, skeletal, muscular,
gastrointestinal, respiratory, lymphatic, and reproduc-
tive systems, has been studied.
Each of these approaches has benefits and deficiencies.
The regional approach works very well if the anatomy
course involves cadaver dissection but falls short when
it comes to understanding the continuity of an entire
system throughout the body. Similarly, the systemic
approach fosters an understanding of an entire system
throughout the body, but it is very difficult to coordinate
this directly with a cadaver dissection or to acquire suffi-
cient detail.
Important anatomical terms
The anatomical position
The anatomical position is the standard reference position
of the body used to describe the location of structures (Fig.
1.1). The body is in the anatomical position when standing
upright with feet together, hands by the side and face
looking forward. The mouth is closed and the facial expres-
sion is neutral. The rim of bone under the eyes is in the
same horizontal plane as the top of the opening to the
ear, and the eyes are open and focused on something in
the distance. The palms of the hands face forward with the
fingers straight and together and with the pad of the thumb
turned 90° to the pads of the fingers. The toes point
forward.
Anatomical planes
Three major groups of planes pass through the body in the
anatomical position (Fig. 1.1).
 What Is Anatomy • Important Anatomical Terms 1
Superior

Coronal plane
Inferior margin of orbit level with
top of external auditory meatus

Face looking forward

Sagittal plane

Anterior Posterior

Medial
Transverse, horizontal,
or axial plane
Hands by sides
palms forward

Lateral

Feet together
toes forward

Inferior

Fig. 1.1 The anatomical position, planes, and terms of location and orientation.

3
 The Body
■ Coronal planes are oriented vertically and divide the
body into anterior and posterior parts.
■ Sagittal planes also are oriented vertically but are at
right angles to the coronal planes and divide the body
into right and left parts. The plane that passes through
the center of the body dividing it into equal right and
left halves is termed the median sagittal plane.
■ Transverse, horizontal, or axial planes divide the
body into superior and inferior parts.
Terms to describe location
Anterior (ventral) and posterior (dorsal),
medial and lateral, superior and inferior
Three major pairs of terms are used to describe the location
of structures relative to the body as a whole or to other
structures (Fig. 1.1).
■ Anterior (or ventral) and posterior (or dorsal)
describe the position of structures relative to the “front”
and “back” of the body. For example, the nose is an
anterior (ventral) structure, whereas the vertebral
column is a posterior (dorsal) structure. Also, the nose
is anterior to the ears and the vertebral column is pos-
terior to the sternum.
■ Medial and lateral describe the position of structures
relative to the median sagittal plane and the sides of
the body. For example, the thumb is lateral to the little
finger. The nose is in the median sagittal plane and
is medial to the eyes, which are in turn medial to the
external ears.
■ Superior and inferior describe structures in reference
to the vertical axis of the body. For example, the head is
superior to the shoulders and the knee joint is inferior
to the hip joint.
Proximal and distal, cranial and caudal,
and rostral
Other terms used to describe positions include proximal
and distal, cranial and caudal, and rostral.
4
■ Proximal and distal are used with reference to being
closer to or farther from a structure’s origin, particu-
larly in the limbs. For example, the hand is distal to the
elbow joint. The glenohumeral joint is proximal to
the elbow joint. These terms are also used to describe
the relative positions of branches along the course of
linear structures, such as airways, vessels, and nerves.
For example, distal branches occur farther away toward
the ends of the system, whereas proximal branches
occur closer to and toward the origin of the system.
■ Cranial (toward the head) and caudal (toward the tail)
are sometimes used instead of superior and inferior,
respectively.
■ Rostral is used, particularly in the head, to describe the
position of a structure with reference to the nose. For
example, the forebrain is rostral to the hindbrain.
Superficial and deep
Two other terms used to describe the position of structures
in the body are superficial and deep. These terms are
used to describe the relative positions of two structures
with respect to the surface of the body. For example, the
sternum is superficial to the heart, and the stomach is deep
to the abdominal wall.
Superficial and deep can also be used in a more absolute
fashion to define two major regions of the body. The super-
ficial region of the body is external to the outer layer of
deep fascia. Deep structures are enclosed by this layer.
Structures in the superficial region of the body include the
skin, superficial fascia, and mammary glands. Deep struc-
tures include most skeletal muscles and viscera. Superficial
wounds are external to the outer layer of deep fascia,
whereas deep wounds penetrate through it.
 Imaging • Diagnostic Imaging Techniques 1

Imaging
Diagnostic imaging techniques Tungsten filament Tungsten target

In 1895 Wilhelm Roentgen used the X-rays from a cathode Focusing cup Glass X-ray tube
ray tube to expose a photographic plate and produce the
first radiographic exposure of his wife’s hand. Over the past
35 years there has been a revolution in body imaging,
which has been paralleled by developments in computer
technology.

Plain radiography
X-rays are photons (a type of electromagnetic radiation)
and are generated from a complex X-ray tube, which is a
type of cathode ray tube (Fig. 1.2). The X-rays are then Cathode Anode
X-rays
collimated (i.e., directed through lead-lined shutters to stop
them from fanning out) to the appropriate area of the body.
As the X-rays pass through the body they are attenuated
(reduced in energy) by the tissues. Those X-rays that pass Fig. 1.2 Cathode ray tube for the production of X-rays.
through the tissues interact with the photographic film.
In the body:

■ air attenuates X-rays a little;

■ fat attenuates X-rays more than air but less than
water; and
■ bone attenuates X-rays the most.

These differences in attenuation result in differences in

the level of exposure of the film. When the photographic
film is developed, bone appears white on the film because
this region of the film has been exposed to the least amount
of X-rays. Air appears dark on the film because these
regions were exposed to the greatest number of X-rays.
Modifications to this X-ray technique allow a continu-
ous stream of X-rays to be produced from the X-ray tube
and collected on an input screen to allow real-time visual-
ization of moving anatomical structures, barium studies,
Fig. 1.3 Fluoroscopy unit.
angiography, and fluoroscopy (Fig. 1.3).

5
 The Body
Contrast agents
To demonstrate specific structures, such as bowel loops or
arteries, it may be necessary to fill these structures with a
substance that attenuates X-rays more than bowel loops or
arteries do normally. It is, however, extremely important
that these substances are nontoxic. Barium sulfate, an
insoluble salt, is a nontoxic, relatively high-density agent
that is extremely useful in the examination of the gastro-
intestinal tract. When a barium sulfate suspension is
ingested it attenuates X-rays and can therefore be used to
demonstrate the bowel lumen (Fig. 1.4). It is common to
add air to the barium sulfate suspension, by either ingest-
ing “fizzy” granules or directly instilling air into the body
cavity, as in a barium enema. This is known as a double-
contrast (air/barium) study.
For some patients it is necessary to inject contrast agents
directly into arteries or veins. In this case, iodine-based
molecules are suitable contrast agents. Iodine is chosen
because it has a relatively high atomic mass and so mark-
edly attenuates X-rays, but also, importantly, it is naturally
excreted via the urinary system. Intra-arterial and intrave-
nous contrast agents are extremely safe and are well toler-
ated by most patients. Rarely, some patients have an
anaphylactic reaction to intra-arterial or intravenous
Fig. 1.4 Barium sulfate follow-through.
6
injections, so the necessary precautions must be taken.
Intra-arterial and intravenous contrast agents not only
help in visualizing the arteries and veins but because they
are excreted by the urinary system, can also be used to
visualize the kidneys, ureter, and bladder in a process
known as intravenous urography.
Subtraction angiography
During angiography it is often difficult to appreciate the
contrast agent in the vessels through the overlying bony
structures. To circumvent this, the technique of subtrac-
tion angiography has been developed. Simply, one or
two images are obtained before the injection of contrast
media. These images are inverted (such that a negative is
created from the positive image). After injection of the
contrast media into the vessels, a further series of images
are obtained, demonstrating the passage of the contrast
through the arteries into the veins and around the circula-
tion. By adding the “negative precontrast image” to the
positive postcontrast images, the bones and soft tissues
are subtracted to produce a solitary image of contrast
only. Before the advent of digital imaging this was a
challenge, but now the use of computers has made this
technique relatively straightforward and instantaneous
(Fig. 1.5).
Fig. 1.5 Digital subtraction angiogram.

Ultrasound
Ultrasonography of the body is widely used for all aspects
of medicine.
Ultrasound is a very high frequency sound wave
(not electromagnetic radiation) generated by piezoelectric
materials, such that a series of sound waves is produced.
Importantly, the piezoelectric material can also receive the
sound waves that bounce back from the internal organs.
The sound waves are then interpreted by a powerful
computer, and a real-time image is produced on the
display panel.
Developments in ultrasound technology, including the
size of the probes and the frequency range, mean that a
broad range of areas can now be scanned.
Traditionally ultrasound is used for assessing the
abdomen (Fig. 1.6) and the fetus in pregnant women.
Ultrasound is also widely used to assess the eyes, neck, soft
tissues, and peripheral musculoskeletal system. Probes
have been placed on endoscopes, and endoluminal ultra-
sound of the esophagus, stomach, and duodenum is now
routine. Endocavity ultrasound is carried out most com-
monly to assess the genital tract in women using a
transvaginal or transrectal route. In men, transrectal
ultrasound is the imaging method of choice to assess the
prostate in those with suspected prostate hypertrophy or
malignancy.
Fig. 1.6 Ultrasound examination of the abdomen.
Imaging • Diagnostic Imaging Techniques 1
Doppler ultrasound
Doppler ultrasound enables determination of flow, its
direction, and its velocity within a vessel using simple
ultrasound techniques. Sound waves bounce off moving
structures and are returned. The degree of frequency shift
determines whether the object is moving away from or
toward the probe and the speed at which it is traveling.
Precise measurements of blood flow and blood velocity can
therefore be obtained, which in turn can indicate sites of
blockage in blood vessels.
Computed tomography
Computed tomography (CT) was invented in the 1970s by
Sir Godfrey Hounsfield, who was awarded the Nobel Prize
in Medicine in 1979. Since this inspired invention there
have been many generations of CT scanners.
A CT scanner obtains a series of images of the body
(slices) in the axial plane. The patient lies on a bed, an
X-ray tube passes around the body (Fig. 1.7), and a series
of images are obtained. A computer carries out a complex
mathematical transformation on the multitude of images
to produce the final image (Fig. 1.8).
Magnetic resonance imaging
Nuclear magnetic resonance imaging was first described in
1946 and used to determine the structure of complex
Fig. 1.7 Computed tomography scanner.
7
 The Body

molecules. The process of magnetic resonance imaging

(MRI) is dependent on the free protons in the hydrogen
nuclei in molecules of water (H2O). Because water is
present in almost all biological tissues, the hydrogen proton
is ideal. The protons within a patient’s hydrogen nuclei can
be regarded as small bar magnets, which are randomly
oriented in space. The patient is placed in a strong magnetic
field, which aligns the bar magnets. When a pulse of radio
waves is passed through the patient the magnets are
deflected, and as they return to their aligned position they
emit small radio pulses. The strength and frequency of the
emitted pulses and the time it takes for the protons to
return to their pre-excited state produce a signal. These
signals are analyzed by a powerful computer, and an image
is created (Fig. 1.9).
By altering the sequence of pulses to which the protons
are subjected, different properties of the protons can be Fig. 1.8 Computed tomography scan of the abdomen at vertebral
level L2.
assessed. These properties are referred to as the “weight-
ing” of the scan. By altering the pulse sequence and the
scanning parameters, T1-weighted images (Fig. 1.10A)
and T2-weighted images (Fig. 1.10B) can be obtained.
These two types of imaging sequences provide differences
in image contrast, which accentuate and optimize different
tissue characteristics.
From the clinical point of view:

■ Most T1-weighted images show dark fluid and bright

fat—for example, within the brain the cerebrospinal
fluid (CSF) is dark.
■ T2-weighted images demonstrate a bright signal from
fluid and an intermediate signal from fat—for example,
in the brain the CSF appears white.

MRI can also be used to assess flow within vessels and

to produce complex angiograms of the peripheral and
cerebral circulation.

Diffusion-weighted imaging
Diffusion-weighted imaging provides information on the
degree of Brownian motion of water molecules in various
tissues. There is relatively free diffusion in extracellular
spaces and more restricted diffusion in intracellular
spaces. In tumors and infarcted tissue, there is an increase
in intracellular fluid water molecules compared with
the extracellular fluid environment resulting in overall
increased restricted diffusion, and therefore identification
of abnormal from normal tissue.
Nuclear medicine imaging
Nuclear medicine involves imaging using gamma rays,
8 which are another type of electromagnetic radiation.
Fig. 1.9 A T2-weighted MR image in the sagittal plane of the
pelvic viscera in a woman.
The important difference between gamma rays and
X-rays is that gamma rays are produced from within the
nucleus of an atom when an unstable nucleus decays,
whereas X-rays are produced by bombarding an atom with
electrons.
For an area to be visualized, the patient must receive a
gamma ray emitter, which must have a number of proper-
ties to be useful, including:
■ a reasonable half-life (e.g., 6 to 24 hours),
■ an easily measurable gamma ray, and
 Imaging • Nuclear Medicine Imaging 1
■ energy deposition in as low a dose as possible in the
patient’s tissues.

The most commonly used radionuclide (radioisotope) is

technetium-99m. This may be injected as a technetium
salt or combined with other complex molecules. For
example, by combining technetium-99m with methylene
diphosphonate (MDP), a radiopharmaceutical is produced.
When injected into the body this radiopharmaceutical
specifically binds to bone, allowing assessment of the
skeleton. Similarly, combining technetium-99m with other
compounds permits assessment of other parts of the body,
for example the urinary tract and cerebral blood flow.
Depending on how the radiopharmaceutical is
absorbed, distributed, metabolized, and excreted by the
body after injection, images are obtained using a gamma
camera (Fig. 1.11).

Positron emission tomography

Positron emission tomography (PET) is an imaging
modality for detecting positron-emitting radionuclides. A
A positron is an anti-electron, which is a positively charged
particle of antimatter. Positrons are emitted from the
decay of proton-rich radionuclides. Most of these radionu-
clides are made in a cyclotron and have extremely short
half-lives.
The most commonly used PET radionuclide is fluorode-
oxyglucose (FDG) labeled with fluorine-18 (a positron

Fig. 1.10 T1-weighted (A) and T2-weighted (B) MR images of the

brain in the coronal plane. Fig. 1.11 A gamma camera.

9
 The Body
emitter). Tissues that are actively metabolizing glucose
take up this compound, and the resulting localized high
concentration of this molecule compared to background
emission is detected as a “hot spot.”
PET has become an important imaging modality in the
detection of cancer and the assessment of its treatment
and recurrence.
Single photon emission computed tomography
Single photon emission computed tomography (SPECT)
is an imaging modality for detecting gamma rays
emitted from the decay of injected radionuclides such as
technetium-99m, iodine-123, or iodine-131. The rays are
detected by a 360-degree rotating camera, which allows the
construction of 3D images. SPECT can be used to diagnose
a wide range of disease conditions such as coronary artery
disease and bone fractures.
IMAGE INTERPRETATION
Imaging is necessary in most clinical specialties to diagnose
pathological changes to tissues. It is paramount to appreci-
ate what is normal and what is abnormal. An appreciation
of how the image is obtained, what the normal variations
are, and what technical considerations are necessary to
obtain a radiological diagnosis. Without understanding the
anatomy of the region imaged, it is impossible to comment
on the abnormal.
Plain radiography
Plain radiographs are undoubtedly the most common form
of image obtained in a hospital or local practice. Before
interpretation, it is important to know about the imaging
technique and the views obtained as standard.
In most instances (apart from chest radiography) the
X-ray tube is 1 m away from the X-ray film. The object in
question, for example a hand or a foot, is placed upon the
film. When describing subject placement for radiography,
the part closest to the X-ray tube is referred to first and that
closest to the film is referred to second. For example, when
positioning a patient for an anteroposterior (AP) radio-
graph, the more anterior part of the body is closest to the
tube and the posterior part is closest to the film.
When X-rays are viewed on a viewing box, the right side
of the patient is placed to the observer’s left; therefore, the
observer views the radiograph as though looking at a
patient in the anatomical position.
Chest radiograph
The chest radiograph is one of the most commonly
requested plain radiographs. An image is taken with the
10 patient erect and placed posteroanteriorly (PA chest
radiograph; that is, with the patient’s back closest to the
X-ray tube.).
Occasionally, when patients are too unwell to stand
erect, films are obtained on the bed in an anteroposterior
(AP) position. These films are less standardized than PA
films, and caution should always be taken when interpret-
ing AP radiographs.
The plain chest radiograph should always be
checked for quality. Film markers should be placed on the
appropriate side. (Occasionally patients have dextrocardia,
which may be misinterpreted if the film marker is placed
inappropriately.) A good-quality chest radiograph will
demonstrate the lungs, cardiomediastinal contour, dia-
phragm, ribs, and peripheral soft tissues.
Abdominal radiograph
Plain abdominal radiographs are obtained in the AP
supine position. From time to time an erect plain abdominal
radiograph is obtained when small bowel obstruction is
suspected.
Gastrointestinal contrast examinations
High-density contrast medium is ingested to opacify the
esophagus, stomach, small bowel, and large bowel. As
described previously (p. 6), the bowel is insufflated with air
(or carbon dioxide) to provide a double-contrast study. In
many countries, endoscopy has superseded upper gastro-
intestinal imaging, but the mainstay of imaging the large
bowel is the double-contrast barium enema. Typically the
patient needs to undergo bowel preparation, in which
powerful cathartics are used to empty the bowel. At the
time of the examination a small tube is placed into the
rectum and a barium suspension is run into the large
bowel. The patient undergoes a series of twists and turns
so that the contrast passes through the entire large bowel.
The contrast is emptied and air is passed through the same
tube to insufflate the large bowel. A thin layer of barium
coats the normal mucosa, allowing mucosal detail to be
visualized (see Fig. 1.4).
Urological contrast studies
Intravenous urography is the standard investigation for
assessing the urinary tract. Intravenous contrast medium
is injected, and images are obtained as the medium is
excreted through the kidneys. A series of films are obtained
during this period from immediately after the injection up
to approximately 20 minutes later, when the bladder is full
of contrast medium.
This series of radiographs demonstrates the kidneys,
ureters, and bladder and enables assessment of the retro-
peritoneum and other structures that may press on the
urinary tract.

Computed tomography
Computed tomography is the preferred terminology rather
than computerized tomography, though both terms are
used interchangeably by physicians.
It is important for the student to understand the presen-
tation of images. Most images are acquired in the axial
plane and viewed such that the observer looks from below
and upward toward the head (from the foot of the bed). By
implication:
■ the right side of the patient is on the left side of the
image, and
■ the uppermost border of the image is anterior.
Many patients are given oral and intravenous contrast
media to differentiate bowel loops from other abdominal
organs and to assess the vascularity of normal anatomical
structures. When intravenous contrast is given, the earlier
the images are obtained, the greater the likelihood of arte-
rial enhancement. As the time is delayed between injection
and image acquisition, a venous phase and an equilibrium
phase are also obtained.
The great advantage of CT scanning is the ability to
extend and compress the gray scale to visualize the bones,
soft tissues, and visceral organs. Altering the window set-
tings and window centering provides the physician with
specific information about these structures.
Imaging • Safety in Imaging 1
and a series of representative films are obtained for
clinical use.
SAFETY IN IMAGING
Whenever a patient undergoes an X-ray or nuclear medi-
cine investigation, a dose of radiation is given (Table 1.1).
As a general principle it is expected that the dose given is
as low as reasonably possible for a diagnostic image to be
obtained. Numerous laws govern the amount of radiation
exposure that a patient can undergo for a variety of proce-
dures, and these are monitored to prevent any excess or
additional dosage. Whenever a radiograph is booked, the
clinician ordering the procedure must appreciate its neces-
sity and understand the dose given to the patient to ensure
that the benefits significantly outweigh the risks.
Imaging modalities such as ultrasound and MRI are
ideal because they do not impart significant risk to the
patient. Moreover, ultrasound imaging is the modality of
choice for assessing the fetus.
Any imaging device is expensive, and consequently
the more complex the imaging technique (e.g., MRI) the
more expensive the investigation. Investigations must be
carried out judiciously, based on a sound clinical history
and examination, for which an understanding of anatomy
is vital.

Magnetic resonance imaging

There is no doubt that MRI has revolutionized the under-
standing and interpretation of the brain and its coverings.
Table 1.1 The approximate dosage of radiation exposure
Furthermore, it has significantly altered the practice of as an order of magnitude
musculoskeletal medicine and surgery. Images can be
Typical Equivalent duration
obtained in any plane and in most sequences. Typically the effective of background
images are viewed using the same principles as CT. Intrave- Examination dose (mSv) exposure
nous contrast agents are also used to further enhance tissue Chest radiograph 0.02 3 days
contrast. Typically, MRI contrast agents contain paramag- Abdomen 1.00 6 months
netic substances (e.g., gadolinium and manganese). Intravenous urography 2.50 14 months

Nuclear medicine imaging CT scan of head 2.30 1 year

CT scan of abdomen 10.00 4.5 years
Most nuclear medicine images are functional studies. and pelvis
Images are usually interpreted directly from a computer,

11
 The Body

Body systems
SKELETAL SYSTEM
The skeleton can be divided into two subgroups, the axial
skeleton and the appendicular skeleton. The axial skeleton
consists of the bones of the skull (cranium), vertebral
column, ribs, and sternum, whereas the appendicular
skeleton consists of the bones of the upper and lower limbs
(Fig. 1.12).
The skeletal system consists of cartilage and bone.

Cartilage
Cartilage is an avascular form of connective tissue consist-
ing of extracellular fibers embedded in a matrix that con-
tains cells localized in small cavities. The amount and kind
of extracellular fibers in the matrix varies depending on the
type of cartilage. In heavy weightbearing areas or areas
prone to pulling forces, the amount of collagen is greatly
increased and the cartilage is almost inextensible. In con-
trast, in areas where weightbearing demands and stress are
less, cartilage containing elastic fibers and fewer collagen
fibers is common. The functions of cartilage are to:

■ support soft tissues,

■ provide a smooth, gliding surface for bone articulations
at joints, and
■ enable the development and growth of long bones.

There are three types of cartilage:

■ hyaline—most common; matrix contains a moderate

amount of collagen fibers (e.g., articular surfaces of
bones);
■ elastic—matrix contains collagen fibers along with a
large number of elastic fibers (e.g., external ear);
Axial skeleton
■ fibrocartilage—matrix contains a limited number of
cells and ground substance amidst a substantial amount Appendicular
skeleton
of collagen fibers (e.g., intervertebral discs).

Cartilage is nourished by diffusion and has no blood Fig. 1.12 The axial skeleton and the appendicular skeleton.
vessels, lymphatics, or nerves.

12
 Body Systems • Skeletal System 1
Bone
Bone is a calcified, living, connective tissue that forms the
majority of the skeleton. It consists of an intercellular
calcified matrix, which also contains collagen fibers, and
several types of cells within the matrix. Bones function as:

■ supportive structures for the body,

■ protectors of vital organs,
■ reservoirs of calcium and phosphorus,
■ levers on which muscles act to produce movement, and
■ containers for blood-producing cells.
Os trigonum
There are two types of bone, compact and spongy (tra-
becular or cancellous). Compact bone is dense bone that
forms the outer shell of all bones and surrounds spongy
bone. Spongy bone consists of spicules of bone enclosing
cavities containing blood-forming cells (marrow). Classifi-
cation of bones is by shape.

■ Long bones are tubular (e.g., humerus in upper limb;

femur in lower limb).
A
■ Short bones are cuboidal (e.g., bones of the wrist and
ankle).
Sesamoid bones
■ Flat bones consist of two compact bone plates separated
by spongy bone (e.g., skull).
■ Irregular bones are bones with various shapes (e.g.,
bones of the face).
■ Sesamoid bones are round or oval bones that develop in
tendons.

In the clinic
Accessory and sesamoid bones
These are extra bones that are not usually found as part of
the normal skeleton, but can exist as a normal variant in
many people. They are typically found in multiple
locations in the wrist and hands, ankles and feet (Fig. 1.13).
These should not be mistaken for fractures on imaging.
Sesamoid bones are embedded within tendons, the
largest of which is the patella. There are many other
sesamoids in the body particularly in tendons of the
hands and feet, and most frequently in flexor tendons of
the thumb and big toe.
Degenerative and inflammatory changes of, as well as Os naviculare
B
mechanical stresses on, the accessory bones and
sesamoids can cause pain, which can be treated with Fig. 1.13 Accessory and sesamoid bones. A. Radiograph of
physiotherapy and targeted steroid injections, but in some the ankle region showing an accessory bone (os trigonum).
severe cases it may be necessary to surgically remove the B. Radiograph of the feet showing numerous sesamoid bones
and an accessory bone (os naviculare).
bone.

13
 The Body

Bones are vascular and are innervated. Generally, an
adjacent artery gives off a nutrient artery, usually one per
bone, that directly enters the internal cavity of the bone
and supplies the marrow, spongy bone, and inner layers of
compact bone. In addition, all bones are covered externally,
except in the area of a joint where articular cartilage is
present, by a fibrous connective tissue membrane called the
periosteum, which has the unique capability of forming new
bone. This membrane receives blood vessels whose branches
supply the outer layers of compact bone. A bone stripped
of its periosteum will not survive. Nerves accompany the
vessels that supply the bone and the periosteum. Most of
the nerves passing into the internal cavity with the nutrient
artery are vasomotor fibers that regulate blood flow. Bone
itself has few sensory nerve fibers. On the other hand, the
periosteum is supplied with numerous sensory nerve fibers
and is very sensitive to any type of injury.
Developmentally, all bones come from mesenchyme by
either intramembranous ossification, in which mesenchy-
mal models of bones undergo ossification, or endochondral
ossification, in which cartilaginous models of bones form
from mesenchyme and undergo ossification.

In the clinic
Determination of skeletal age
Throughout life the bones develop in a predictable way to
form the skeletally mature adult at the end of puberty. In
western countries skeletal maturity tends to occur between
the ages of 20 and 25 years. However, this may well vary
according to geography and socioeconomic conditions.
Skeletal maturity will also be determined by genetic factors
and disease states.
Up until the age of skeletal maturity, bony growth and
development follows a typically predictable ordered state,
which can be measured through either ultrasound, plain
radiographs, or MRI scanning. Typically, the nondominant
(left) hand is radiographed, and the radiograph is compared A B
to a series of standard radiographs. From these images the
bone age can be determined (Fig. 1.14).
In certain disease states, such as malnutrition and
hypothyroidism, bony maturity may be slow. If the skeletal
bone age is significantly reduced from the patient’s true age,
treatment may be required.
In the healthy individual the bone age accurately
represents the true age of the patient. This is important in
determining the true age of the subject. This may also have
medicolegal importance. Carpal
bones

C D

Fig. 1.14 A developmental series of radiographs showing the

progressive ossification of carpal (wrist) bones from 3 (A) to 10
(D) years of age.

14
 Body Systems • Skeletal System 1
In the clinic
Bone marrow transplants Red marrow in body
of lumbar vertebra
The bone marrow serves an important function. There are
two types of bone marrow, red marrow (otherwise known
as myeloid tissue) and yellow marrow. Red blood cells,
platelets, and most white blood cells arise from within the
red marrow. In the yellow marrow a few white cells are
made; however, this marrow is dominated by large fat
globules (producing its yellow appearance) (Fig. 1.15).
From birth most of the body’s marrow is red; however,
as the subject ages, more red marrow is converted into
yellow marrow within the medulla of the long and
flat bones.
Bone marrow contains two types of stem cells.
Hemopoietic stem cells give rise to the white blood cells,
red blood cells, and platelets. Mesenchymal stem cells
differentiate into structures that form bone, cartilage,
and muscle.
There are a number of diseases that may involve the
bone marrow, including infection and malignancy. In patients
who develop a bone marrow malignancy (e.g., leukemia) it
may be possible to harvest nonmalignant cells from the
patient’s bone marrow or cells from another person’s bone
marrow. The patient’s own marrow can be destroyed with Yellow marrow in femoral head
chemotherapy or radiation and the new cells infused. This
treatment is bone marrow transplantation. Fig. 1.15 T1-weighted image in the coronal plane,
demonstrating the relatively high signal intensity returned from
the femoral heads and proximal femoral necks, consistent with
yellow marrow. In this young patient, the vertebral bodies return
an intermediate darker signal that represents red marrow. There
is relatively little fat in these vertebrae; hence the lower signal
return.

15
 The Body

In the clinic
Bone fractures
Fractures occur in normal bone because of abnormal load or
stress, in which the bone gives way (Fig. 1.16A). Fractures
may also occur in bone that is of poor quality (osteoporosis);
in such cases a normal stress is placed upon a bone that is
not of sufficient quality to withstand this force and
subsequently fractures.
In children whose bones are still developing, fractures
may occur across the growth plate or across the shaft. These
shaft fractures typically involve partial cortical disruption,
similar to breaking a branch of a young tree; hence they are
A
termed “greenstick” fractures.
After a fracture has occurred, the natural response is to
heal the fracture. Between the fracture margins a blood clot
is formed into which new vessels grow. A jelly-like matrix is
formed, and further migration of collagen-producing cells
occurs. On this soft tissue framework, calcium
hydroxyapatite is produced by osteoblasts and forms
insoluble crystals, and then bone matrix is laid down. As
more bone is produced, a callus can be demonstrated
forming across the fracture site. B
Treatment of fractures requires a fracture line reduction. If
this cannot be maintained in a plaster of Paris cast, it may
Fig. 1.16 Radiograph, lateral view, showing fracture of the ulna
require internal or external fixation with screws and metal at the elbow joint (A) and repair of this fracture (B) using
rods (Fig. 1.16B). internal fixation with a plate and multiple screws.

In the clinic
Avascular necrosis Wasting of gluteal muscle
Avascular necrosis is cellular death of bone resulting from a
temporary or permanent loss of blood supply to that bone.
Avascular necrosis may occur in a variety of medical
conditions, some of which have an etiology that is less than
clear. A typical site for avascular necrosis is a fracture across
the femoral neck in an elderly patient. In these patients there
is loss of continuity of the cortical medullary blood flow with
loss of blood flow deep to the retinacular fibers. This
essentially renders the femoral head bloodless; it
subsequently undergoes necrosis and collapses (Fig. 1.17). In
these patients it is necessary to replace the femoral head
with a prosthesis.

Avascular necrosis Bladder Normal left hip

Fig. 1.17 Image of the hip joints demonstrating loss of height of

the right femoral head with juxta-articular bony sclerosis and
subchondral cyst formation secondary to avascular necrosis.
There is also significant wasting of the muscles supporting the
hip, which is secondary to disuse and pain.
16
 Body Systems • Skeletal System 1
In the clinic
Epiphyseal fractures
As the skeleton develops, there are stages of intense
growth typically around the ages of 7 to 10 years and later
in puberty. These growth spurts are associated with
increased cellular activity around the growth plate
between the head and shaft of a bone. This increase in
activity renders the growth plates more vulnerable to
injuries, which may occur from dislocation across a Bone Articular cavity Bone
growth plate or fracture through a growth plate.
A Synovial joint
Occasionally an injury may result in growth plate
compression, destroying that region of the growth plate,
which may result in asymmetrical growth across that joint
region. All fractures across the growth plate must be
treated with care and expediency, requiring fracture
reduction.

Bone Connective tissue Bone

B Solid joint

Joints Fig. 1.18 Joints. A. Synovial joint. B. Solid joint.

The sites where two skeletal elements come together

are termed joints. The two general categories of joints
(Fig. 1.18) are those in which:
■ the skeletal elements are separated by a cavity (i.e.,
synovial joints), and
■ there is no cavity and the components are held together
by connective tissue (i.e., solid joints).
Blood vessels that cross over a joint and nerves that
innervate muscles acting on a joint usually contribute
articular branches to that joint.
Synovial joints
Synovial joints are connections between skeletal compo-
nents where the elements involved are separated by a
narrow articular cavity (Fig. 1.19). In addition to contain-
ing an articular cavity, these joints have a number of
characteristic features.
First, a layer of cartilage, usually hyaline cartilage,
covers the articulating surfaces of the skeletal elements. In
other words, bony surfaces do not normally contact one
another directly. As a consequence, when these joints are
viewed in normal radiographs, a wide gap seems to sepa-
rate the adjacent bones because the cartilage that covers
the articulating surfaces is more transparent to X-rays
than bone.
A second characteristic feature of synovial joints is the
presence of a joint capsule consisting of an inner syno-
vial membrane and an outer fibrous membrane.
■ The synovial membrane attaches to the margins of the
joint surfaces at the interface between the cartilage and
bone and encloses the articular cavity. The synovial
membrane is highly vascular and produces synovial
fluid, which percolates into the articular cavity and
lubricates the articulating surfaces. Closed sacs of
synovial membrane also occur outside joints, where
they form synovial bursae or tendon sheaths. Bursae
often intervene between structures, such as tendons
and bone, tendons and joints, or skin and bone, and
reduce the friction of one structure moving over the
other. Tendon sheaths surround tendons and also
reduce friction.
■ The fibrous membrane is formed by dense connective
tissue and surrounds and stabilizes the joint. Parts of
the fibrous membrane may thicken to form ligaments,
which further stabilize the joint. Ligaments outside the
capsule usually provide additional reinforcement.
Another common but not universal feature of synovial
joints is the presence of additional structures within the
area enclosed by the capsule or synovial membrane, such
as articular discs (usually composed of fibrocartilage),
fat pads, and tendons. Articular discs absorb compres-
sion forces, adjust to changes in the contours of joint sur-
faces during movements, and increase the range of
movements that can occur at joints. Fat pads usually occur
between the synovial membrane and the capsule and move 17
 The Body

Tendon
Sheath

Synovial Hyaline cartilage

membrane Fat pad
Joint
capsule
Articular cavity

Fibrous Articular
membrane disc

Bone
Bone
Hyaline
cartilage
Bone

Articular cavity Bone

Fibrous
membrane
Synovial
Skin Bursa membrane
A B

Fig. 1.19 Synovial joints. A. Major features of a synovial joint. B. Accessory structures associated with synovial joints.

into and out of regions as joint contours change during
movement. Redundant regions of the synovial membrane
and fibrous membrane allow for large movements at joints.
Descriptions of synovial joints based on shape
and movement
Synovial joints are described based on shape and
movement:
■ based on the shape of their articular surfaces, synovial
joints are described as plane (flat), hinge, pivot,
bicondylar (two sets of contact points), condylar (ellip-
soid), saddle, and ball and socket;
■ based on movement, synovial joints are described as
uniaxial (movement in one plane), biaxial (movement
in two planes), and multiaxial (movement in three
planes).
Hinge joints are uniaxial, whereas ball and socket joints
are multiaxial.

18

Specific types of synovial joints
(Fig. 1.20)
■ Plane joints—allow sliding or gliding movements when
one bone moves across the surface of another (e.g.,
acromioclavicular joint)
■ Hinge joints—allow movement around one axis that
passes transversely through the joint; permit flexion and
extension (e.g., elbow [humero-ulnar] joint)
■ Pivot joints—allow movement around one axis that
passes longitudinally along the shaft of the bone; permit
rotation (e.g., atlanto-axial joint)
■ Bicondylar joints—allow movement mostly in one axis
with limited rotation around a second axis; formed by
two convex condyles that articulate with concave or flat
surfaces (e.g., knee joint)
■ Condylar (ellipsoid) joints—allow movement around
two axes that are at right angles to each other; permit
flexion, extension, abduction, adduction, and circum-
duction (limited) (e.g., wrist joint)
■ Saddle joints—allow movement around two axes that
are at right angles to each other; the articular surfaces
are saddle shaped; permit flexion, extension, abduction,
adduction, and circumduction (e.g., carpometacarpal
joint of the thumb)
■ Ball and socket joints—allow movement around
multiple axes; permit flexion, extension, abduction,
Body Systems • Skeletal System 1
adduction, circumduction, and rotation (e.g., hip
joint)
Solid joints
Solid joints are connections between skeletal elements
where the adjacent surfaces are linked together either
by fibrous connective tissue or by cartilage, usually fibro-
cartilage (Fig. 1.21). Movements at these joints are more
restricted than at synovial joints.
Fibrous joints include sutures, gomphoses, and
syndesmoses.
■ Sutures occur only in the skull where adjacent bones
are linked by a thin layer of connective tissue termed a
sutural ligament.
■ Gomphoses occur only between the teeth and adjacent
bone. In these joints, short collagen tissue fibers in the
periodontal ligament run between the root of the tooth
and the bony socket.
■ Syndesmoses are joints in which two adjacent bones
are linked by a ligament. Examples are the ligamentum
flavum, which connects adjacent vertebral laminae,
and an interosseous membrane, which links, for
example, the radius and ulna in the forearm.
Cartilaginous joints include synchondroses and
symphyses.

B Humerus

Ulna Radius
Synovial membrane

Wrist joint
Articular disc
Radius
Olecranon
A Synovial cavity C Ulna

Odontoid process
Cartilage of axis

Trapezium
Synovial membrane

Atlas
Metacarpal I
Synovial
Femur membrane

D E F

Fig. 1.20 Various types of synovial joints. A. Condylar (wrist). B. Gliding (radio-ulnar). C. Hinge (elbow). D. Ball and socket (hip). E. Saddle 19
(carpometacarpal of thumb). F. Pivot (atlanto-axial).
 The Body

SOLID JOINTS

Fibrous Cartilaginous

Sutures
Sutural ligament

Skull Synchondrosis

Head

Gomphosis
Cartilage of
growth plate

Tooth Long bone

Shaft
Periodontal
ligament

Bone

Symphysis

Intervertebral
Syndesmosis
discs

Radius Ulna

Interosseous
membrane
Pubic
symphysis

Fig. 1.21 Solid joints.

■ Synchondroses occur where two ossification centers
in a developing bone remain separated by a layer of
cartilage, for example, the growth plate that occurs
between the head and shaft of developing long bones.
These joints allow bone growth and eventually become
20 completely ossified.
■ Symphyses occur where two separate bones are inter-
connected by cartilage. Most of these types of joints
occur in the midline and include the pubic symphysis
between the two pelvic bones, and intervertebral discs
between adjacent vertebrae.

In the clinic
Degenerative joint disease
Degenerative joint disease is commonly known as
osteoarthritis or osteoarthrosis. The disorder is related to
aging but not caused by aging. Typically there are decreases
in water and proteoglycan content within the cartilage. The
cartilage becomes more fragile and more susceptible to
mechanical disruption (Fig. 1.22). As the cartilage wears, the
underlying bone becomes fissured and also thickens.
Synovial fluid may be forced into small cracks that appear in
the bone’s surface, which produces large cysts. Furthermore,
reactive juxta-articular bony nodules are formed
(osteophytes) (Fig. 1.23). As these processes occur, there is
slight deformation, which alters the biomechanical forces
through the joint. This in turn creates abnormal stresses,
which further disrupt the joint.
Cartilage loss Patella
Femoral condyles Cartilage loss
Fig. 1.22 This operative photograph demonstrates the focal
areas of cartilage loss in the patella and femoral condyles
throughout the knee joint.
Body Systems • Skeletal System 1
In the United States, osteoarthritis accounts for up to
one-quarter of primary health care visits and is regarded as a
significant problem.
The etiology of osteoarthritis is not clear; however,
osteoarthritis can occur secondary to other joint diseases,
such as rheumatoid arthritis and infection. Overuse of joints
and abnormal strains, such as those experienced by people
who play sports, often cause one to be more susceptible to
chronic joint osteoarthritis.
Various treatments are available, including weight
reduction, proper exercise, anti-inflammatory drug treatment,
and joint replacement (Fig. 1.24).
Osteophytes
Loss of joint space
Fig. 1.23 This radiograph demonstrates the loss of joint space in
the medial compartment and presence of small spiky
osteophytic regions at the medial lateral aspect of the joint.
21
 The Body

In the clinic—cont’d
Arthroscopy
Arthroscopy is a technique of visualizing the inside of a joint
using a small telescope placed through a tiny incision in the
skin. Arthroscopy can be performed in most joints. However,
it is most commonly performed in the knee, shoulder, ankle,
and hip joints.
Arthroscopy allows the surgeon to view the inside of the
joint and its contents. Notably, in the knee, the menisci and
the ligaments are easily seen, and it is possible using
separate puncture sites and specific instruments to remove
the menisci and replace the cruciate ligaments. The
advantages of arthroscopy are that it is performed through
small incisions, it enables patients to quickly recover and
return to normal activity, and it only requires either a light
anesthetic or regional anesthesia during the procedure.

Fig. 1.24 After knee replacement. This radiograph shows the

position of the prosthesis.

In the clinic
Joint replacement
Joint replacement is undertaken for a variety of reasons.
These predominantly include degenerative joint disease and
joint destruction. Joints that have severely degenerated or
lack their normal function are painful. In some patients, the
pain may be so severe that it prevents them from leaving
the house and undertaking even the smallest of activities
without discomfort.
Large joints are commonly affected, including the hip,
knee, and shoulder. However, with ongoing developments
in joint replacement materials and surgical techniques, even
small joints of the fingers can be replaced.
Typically, both sides of the joint are replaced; in the hip
joint the acetabulum will be reamed, and a plastic or metal
cup will be introduced. The femoral component will be fitted
precisely to the femur and cemented in place (Fig. 1.25).
Most patients derive significant benefit from joint
replacement and continue to lead an active life afterward. In
a minority of patients who have been fitted with a metal
acetabular cup and metal femoral component, an aseptic
lymphocyte-dominated vasculitis-associated lesion (ALVAL)
may develop, possibly caused by a hypersensitivity response
to the release of metal ions in adjacent tissues. These Artificial femoral head Acetabulum
patients often have chronic pain and might need additional
surgery to replace these joint replacements with safer Fig. 1.25 This is a radiograph, anteroposterior view, of the
models. pelvis after a right total hip replacement. There are additional
significant degenerative changes in the left hip joint, which will
also need to be replaced.
22

SKIN AND FASCIAS
Skin
The skin is the largest organ of the body. It consists of the
epidermis and the dermis. The epidermis is the outer cel-
lular layer of stratified squamous epithelium, which is
avascular and varies in thickness. The dermis is a dense bed
of vascular connective tissue.
The skin functions as a mechanical and permeability
barrier, and as a sensory and thermoregulatory organ. It
also can initiate primary immune responses.
Fascia
Fascia is connective tissue containing varying amounts of
fat that separate, support, and interconnect organs and
structures, enable movement of one structure relative to
another, and allow the transit of vessels and nerves from
one area to another. There are two general categories of
fascia: superficial and deep.
■ Superficial (subcutaneous) fascia lies just deep to and is
attached to the dermis of the skin. It is made up of loose
connective tissue usually containing a large amount of
fat. The thickness of the superficial fascia (subcutane-
ous tissue) varies considerably, both from one area of
the body to another and from one individual to another.
The superficial fascia allows movement of the skin over
deeper areas of the body, acts as a conduit for vessels and
nerves coursing to and from the skin, and serves as an
energy (fat) reservoir.
■ Deep fascia usually consists of dense, organized connec-
tive tissue. The outer layer of deep fascia is attached to
the deep surface of the superficial fascia and forms a
thin fibrous covering over most of the deeper region of
the body. Inward extensions of this fascial layer form
intermuscular septa that compartmentalize groups of
muscles with similar functions and innervations. Other
extensions surround individual muscles and groups of
vessels and nerves, forming an investing fascia. Near
some joints the deep fascia thickens, forming retinacula.
These fascial retinacula hold tendons in place and
prevent them from bowing during movements at the
joints. Finally, there is a layer of deep fascia separating
the membrane lining the abdominal cavity (the parietal
peritoneum) from the fascia covering the deep surface
of the muscles of the abdominal wall (the transversalis
fascia). This layer is referred to as extraperitoneal
fascia. A similar layer of fascia in the thorax is termed
the endothoracic fascia.
Body Systems • Muscular System 1
In the clinic
The importance of fascias
A fascia is a thin band of tissue that surrounds muscles,
bones, organs, nerves, and blood vessels and often
remains uninterrupted as a 3D structure between tissues. It
provides important support for tissues and can provide a
boundary between structures.
Clinically, fascias are extremely important because they
often limit the spread of infection and malignant disease.
When infections or malignant diseases cross a fascial
plain, a primary surgical clearance may require a far more
extensive dissection to render the area free of tumor or
infection.
A typical example of the clinical importance of a fascial
layer would be of that covering the psoas muscle.
Infection within an intervertebral body secondary to
tuberculosis can pass laterally into the psoas muscle. Pus
fills the psoas muscle but is limited from further spread by
the psoas fascia, which surrounds the muscle and extends
inferiorly into the groin pointing below the inguinal
ligament.
In the clinic
Placement of skin incisions and scarring
Surgical skin incisions are ideally placed along or parallel
to Langer’s lines, which are lines of skin tension that
correspond to the orientation of the dermal collagen
fibers. They tend to run in the same direction as the
underlying muscle fibers and incisions that are made
along these lines tend to heal better with less scarring. In
contrast, incisions made perpendicular to Langer’s lines
are more likely to heal with a prominent scar and in some
severe cases can lead to raised, firm, hypertrophic, or
keloid, scars.
MUSCULAR SYSTEM
The muscular system is generally regarded as consisting of
one type of muscle found in the body—skeletal muscle.
However, there are two other types of muscle tissue found
in the body, smooth muscle and cardiac muscle, that are
important components of other systems. These three types
of muscle can be characterized by whether they are con-
trolled voluntarily or involuntarily, whether they appear
striated (striped) or smooth, and whether they are associ-
ated with the body wall (somatic) or with organs and blood
vessels (visceral).
■ Skeletal muscle forms the majority of the muscle tissue
in the body. It consists of parallel bundles of long,
23
 The Body

multinucleated fibers with transverse stripes, is capable

of powerful contractions, and is innervated by somatic
and branchial motor nerves. This muscle is used to
move bones and other structures, and provides support
and gives form to the body. Individual skeletal muscles
are often named on the basis of shape (e.g., rhomboid
major muscle), attachments (e.g., sternohyoid muscle),
function (e.g., flexor pollicis longus muscle), position
(e.g., palmar interosseous muscle), or fiber orientation
(e.g., external oblique muscle).
■ Cardiac muscle is striated muscle found only in the walls
of the heart (myocardium) and in some of the large
vessels close to where they join the heart. It consists of
a branching network of individual cells linked electri-
cally and mechanically to work as a unit. Its contrac-
tions are less powerful than those of skeletal muscle and
it is resistant to fatigue. Cardiac muscle is innervated by
visceral motor nerves.
■ Smooth muscle (absence of stripes) consists of elongated
or spindle-shaped fibers capable of slow and sustained
contractions. It is found in the walls of blood vessels
(tunica media), associated with hair follicles in the skin,
located in the eyeball, and found in the walls of various
structures associated with the gastrointestinal, respira-
tory, genitourinary, and urogenital systems. Smooth
muscle is innervated by visceral motor nerves.
In the clinic
Muscle paralysis
Muscle paralysis is the inability to move a specific muscle
or muscle group and may be associated with other
neurological abnormalities, including loss of sensation.
Major causes include stroke, trauma, poliomyelitis, and
iatrogenic factors. Paralysis may be due to abnormalities
in the brain, the spinal cord, and the nerves supplying the
muscles.
In the long term, muscle paralysis will produce
secondary muscle wasting and overall atrophy of the
region due to disuse.
In the clinic
Muscle atrophy
Muscle atrophy is a wasting disorder of muscle. It can be
produced by a variety of causes, which include nerve
damage to the muscle and disuse.
Muscle atrophy is an important problem in patients
who have undergone long-term rest or disuse, requiring
extensive rehabilitation and muscle building exercises to
maintain normal activities of daily living.

In the clinic
Muscle injuries and strains identify which muscle groups are affected and the extent of
Muscle injuries and strains tend to occur in specific muscle the tear to facilitate treatment and obtain a prognosis, which
groups and usually are related to a sudden exertion and will determine the length of rehabilitation necessary to
muscle disruption. They typically occur in athletes. return to normal activity.
Muscle tears may involve a small interstitial injury up to a
complete muscle disruption (Fig. 1.26). It is important to

Fig. 1.26 Axial inversion recovery MR imaging

series, which suppresses fat and soft tissue and
leaves high signal intensity where fluid is seen.
A muscle tear in the right adductor longus with
edema in and around the muscle is shown. Torn right adductor longus Normal left adductor longus
24

CARDIOVASCULAR SYSTEM
The cardiovascular system consists of the heart, which
pumps blood throughout the body, and the blood vessels,
which are a closed network of tubes that transport the
blood. There are three types of blood vessels:
■ arteries, which transport blood away from the heart;
■ veins, which transport blood toward the heart;
■ capillaries, which connect the arteries and veins, are the
smallest of the blood vessels and are where oxygen,
nutrients, and wastes are exchanged within the tissues.
The walls of the blood vessels of the cardiovascular
system usually consist of three layers or tunics:
■ tunica externa (adventitia)—the outer connective tissue
layer,
■ tunica media—the middle smooth muscle layer (may
also contain varying amounts of elastic fibers in medium
and large arteries), and
■ tunica intima—the inner endothelial lining of the blood
vessels.
Arteries are usually further subdivided into three
classes, according to the variable amounts of smooth
muscle and elastic fibers contributing to the thickness of
the tunica media, the overall size of the vessel, and its
function.
■ Large elastic arteries contain substantial amounts of
elastic fibers in the tunica media, allowing expansion
and recoil during the normal cardiac cycle. This helps
maintain a constant flow of blood during diastole.
Examples of large elastic arteries are the aorta, the
brachiocephalic trunk, the left common carotid artery,
the left subclavian artery, and the pulmonary trunk.
■ Medium muscular arteries are composed of a tunica
media that contains mostly smooth muscle fibers. This
characteristic allows these vessels to regulate their
diameter and control the flow of blood to different parts
of the body. Examples of medium muscular arteries are
most of the named arteries, including the femoral, axil-
lary, and radial arteries.
■ Small arteries and arterioles control the filling of the
capillaries and directly contribute to the arterial pres-
sure in the vascular system.
Veins also are subdivided into three classes.
■ Large veins contain some smooth muscle in the tunica
media, but the thickest layer is the tunica externa.
Body Systems • Cardiovascular System 1
Examples of large veins are the superior vena cava, the
inferior vena cava, and the portal vein.
■ Small and medium veins contain small amounts of
smooth muscle, and the thickest layer is the tunica
externa. Examples of small and medium veins are
superficial veins in the upper and lower limbs and
deeper veins of the leg and forearm.
■ Venules are the smallest veins and drain the
capillaries.
Although veins are similar in general structure to arter-
ies, they have a number of distinguishing features.
■ The walls of veins, specifically the tunica media, are
thin.
■ The luminal diameters of veins are large.
■ There often are multiple veins (venae comitantes) closely
associated with arteries in peripheral regions.
■ Valves often are present in veins, particularly in periph-
eral vessels inferior to the level of the heart. These are
usually paired cusps that facilitate blood flow toward
the heart.
More specific information about the cardiovascular
system and how it relates to the circulation of blood
throughout the body will be discussed, where appropriate,
in each of the succeeding chapters of the text.
In the clinic
Atherosclerosis
Atherosclerosis is a disease that affects arteries. There is a
chronic inflammatory reaction in the walls of the arteries,
with deposition of cholesterol and fatty proteins. This may
in turn lead to secondary calcification, with reduction in
the diameter of the vessels impeding distal flow. The
plaque itself may be a site for attraction of platelets that
may “fall off” (embolize) distally. Plaque fissuring may
occur, which allows fresh clots to form and occlude the
vessel.
The importance of atherosclerosis and its effects
depend upon which vessel is affected. If atherosclerosis
occurs in the carotid artery, small emboli may form and
produce a stroke. In the heart, plaque fissuring may
produce an acute vessel thrombosis, producing a
myocardial infarction (heart attack). In the legs, chronic
narrowing of vessels may limit the ability of the patient to
walk and ultimately cause distal ischemia and gangrene of
the toes.
25
 The Body

In the clinic
Varicose veins Varicose veins
Varicose veins are tortuous dilated veins that typically occur
in the legs, although they may occur in the superficial veins
of the arm and in other organs.
In normal individuals the movement of adjacent leg
muscles pumps the blood in the veins to the heart. Blood is
also pumped from the superficial veins through the investing
layer of fascia of the leg into the deep veins. Valves in these
perforating veins may become damaged, allowing blood to
pass in the opposite direction. This increased volume and
pressure produces dilatation and tortuosity of the superficial
veins (Fig. 1.27). Apart from the unsightliness of larger veins,
the skin may become pigmented and atrophic with a poor
response to tissue trauma. In some patients even small
trauma may produce skin ulceration, which requires
elevation of the limb and application of pressure bandages
to heal.
Treatment of varicose veins depends on their location,
size, and severity. Typically the superficial varicose veins can
be excised and stripped, allowing blood only to drain into
the deep system.

Fig. 1.27 Photograph demonstrating varicose veins.

In the clinic
Anastomoses and collateral circulation
All organs require a blood supply from the arteries and
drainage by veins. Within most organs there are multiple
ways of perfusing the tissue such that if the main vessel
feeding the organ or vein draining the organ is blocked, a
series of smaller vessels (collateral vessels) continue to
supply and drain the organ.
In certain circumstances, organs have more than one
vessel perfusing them, such as the hand, which is supplied
by the radial and ulnar arteries. Loss of either the radial or
the ulnar artery may not produce any symptoms of reduced
perfusion to the hand.
There are circumstances in which loss of a vein produces
significant venous collateralization. Some of these venous
collaterals become susceptible to bleeding. This is a
considerable problem in patients who have undergone portal
vein thrombosis or occlusion, where venous drainage from
the gut bypasses the liver through collateral veins to return
to the systemic circulation.
Normal vascular anastomoses associated with an organ
are important. Some organs, such as the duodenum, have a
dual blood supply arising from the branches of the celiac
trunk and also from the branches of the superior mesenteric
artery. Should either of these vessels be damaged, blood
supply will be maintained to the organ. The brain has
multiple vessels supplying it, dominated by the carotid
arteries and the vertebral arteries. Vessels within the brain
are end arteries and have a poor collateral circulation; hence
any occlusion will produce long-term cerebral damage.

26
Another random document with
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sentiva spuntarsi una lacrima. Non poteva a meno di rievocare il
tempo in cui que’ suoi cari rallegravano il tetto domestico e
scherzavano sulle ginocchia materne. Ahimè, ormai la madre era
morta da un pezzo.... Involontariamente l’occhio del colonnello si
posava sulla parete ove sotto i ritratti di Vittorio Emanuele, di
Umberto, di Garibaldi, di Lamarmora, di Napoleone III, ecc., ecc.,
c’era un gruppo di fotografie di famiglia. La più antica e sbiadita era
appunto quella di sua moglie, una donna esile, dall’aria stanca e
sofferente. A fianco di lei Bedeschi in persona, in uniforme, con la
sua medaglia al valor militare sul petto, con la sua mano bravamente
piantata sull’elsa della sciabola. Qualche linea più sotto l’effigie di tre
giovinotti, Vittorio, Augusto, ed un terzo, minore di tutti.
Sicuro, c’era un terzo figliuolo, Federico, ed egli solo non s’era fatto
vivo in quel giorno, e da Londra, dove si trovava, non aveva spedito
nè una lettera, nè un dispaccio. Quando Bedeschi pensava a questo
ragazzo ch’era stato il suo preferito egli si doleva di aver ceduto una
volta tanto alle preghiere di sua moglie, la quale, impuntatasi
nell’idea che Federico fosse di salute cagionevole, aveva, tra gemiti
e singhiozzi, scongiurato il marito di non fargli abbracciar la carriera
militare come i fratelli, e strappatagliene un giorno a malincuore la
promessa, se l’era fatta rinnovare solennemente al letto di morte.
Federico era quindi rimasto in casa, aveva frequentate le scuole
pubbliche, ed era giunto senza gloria fino all’università. Non gli
mancava nè cuore nè ingegno, ma aveva uno spirito indisciplinato,
ripugnante a studi regolari, turbato piuttosto da vaghe inquietudini
d’artista. Onde nel bel mezzo del corso di legge gli era saltato il
ghiribizzo di darsi alla pittura, con grande sdegno del colonnello, il
quale nè amava l’arte, nè credeva a questa vocazione improvvisa.
N’eran seguite scene violente, per merito delle quali Federico aveva
finito col non studiar nè pittura nè legge e col menare una vita oziosa
e dissipata. Allora il padre gli aveva posto un dilemma. O mettersi in
grado di prendere la laurea entro un anno, o partire subito per
Londra, ove un antico compagno di cospirazioni del colonnello,
arricchitosi nel commercio, impiegava volentieri dei giovani italiani
per mandarli, dopo un tirocinio più o meno lungo, presso le sue case
filiali di San Francisco o di Sidney. Federico che della laurea non
voleva saperne accettò la seconda proposta; meglio far il minatore in
California o il pastore in Australia che incretinirsi su una scranna di
giudice o assottigliare il cervello nei cavilli avvocateschi.
E partì con una cert’aria spavalda che il colonnello, cattivo psicologo,
attribuì a perversità d’animo, mentre Federico, dal canto suo,
risentiva profondamente l’affettata indifferenza del padre. Come
avviene quando c’è un equivoco che non si chiarisce subito, la
freddezza reciproca andò a mano a mano crescendo; padre e
figliuolo si accusavano in silenzio di poco cuore e non si
scambiavano che lettere brevi, fredde e insignificanti.
Frattanto entrò in casa la Bice portando nella dimora solitaria un
nuovo alito di giovinezza, togliendole quell’aspetto triste e desolato
ch’essa aveva nelle prime settimane dell’assenza di Federico. Senza
volerlo, senza saperlo, la fanciulla nuoceva al cugino. Una frase
dello zio lo mise in guardia. — Non parliamo di quello scapato. —
egli le disse. — Ora sei tu che ne tieni il posto.
Tenere il posto di Federico? No, ciò non poteva, non doveva essere.
Ed ella dichiarò allo zio che prima che accadesse una cosa simile
sarebbe tornata in collegio, sicura di farvisi accettare dalla direttrice
come assistente.
Alla lunga si calmò, ma fermando il proposito di esercitar tutta la
propria influenza per sopire quel dissidio domestico. Pur non tardò
ad accorgersi che l’impresa era ardua ed esigeva infinite cautele.
Non le fu difficile mettersi in relazione con Federico, avendola lo zio
stesso incaricata talora di scrivergli in vece sua. E Federico le
rispose in principio diffidente e guardingo, poi, via via, più sciolto ed
espansivo. A lei rivelava la tristezza del suo esilio, l’acuta nostalgia
da cui era sovente assalito, la sua ripugnanza ad allontanarsi ancora
di più dall’Italia, la sua sfiducia assoluta di far buona prova nella
mercatura. Ma soprattutto le discorreva dell’arte, ch’egli aveva
ripreso ad amar con passione, che coltivava in segreto, e nella quale
avrebbe potuto forse non esser degli ultimi se gli fosse stato
permesso di dedicarvisi intero.
Il colonnello Bedeschi aveva tempra di despota, non d’inquisitore, e
avrebbe stimato inferiore alla sua dignità lo spiar le corrispondenze
della nipote. Delle lettere ch’ella riceveva da Federico egli sapeva
quel tanto che a lei piaceva di dirgliene, ed è naturale ch’ella gliene
presentasse un’edizione riveduta e corretta. Accennava alla
condotta regolare del giovine, al desiderio ch’egli manifestava di
riacquistare l’affetto e la stima del padre.... soggiungendo
timidamente che a parer suo non c’era ragione di tenerlo più oltre in
castigo a Londra, e meno che mai di spedirlo in capo al mondo.
La prima volta che la Bice toccò questo tasto, Bedeschi montò su
tutte le furie. — O ch’ella pretendeva di dargli lezioni? Ella, una
bambina, con quell’esperienza che aveva? Badasse ai casi suoi e
non s’impicciasse di ciò che non la riguardava. Se Federico le
scriveva delle sciocchezze, padrone; e padrona lei di rispondergliene
altrettante, ma non venisse a far la saccente. Aveva capito?
La fanciulla non si smarrì d’animo per questo rabbuffo nè perdette di
vista la sua meta. A ogni occasione opportuna ella tornava alla
carica, sopportando in santa pace le sfuriate dello zio, il quale, in
cuor suo, non si rammaricava troppo ch’ella difendesse il cugino. Ma
il colonnello aveva riputazione d’uomo forte, d’uomo inflessibile, e
certe riputazioni sono come un patrimonio da conservare. Bedeschi
non voleva che si dicesse ch’egli s’infemminiva cogli anni. Accadeva
poi un fatto curioso. Quantunque egli non osasse confessarlo a sè
stesso, la Bice gli diventava più cara per la sua generosità nel
prender le parti di Federico, e appunto col diventargli più cara gli
rendeva meno sensibile la mancanza del figlio.
S’era sbagliata strada. La Bice lo riconobbe e mutò tattica. Da due o
tre mesi ella non parlava di Federico che quand’era strettamente
necessario il parlarne, pareva rassegnata non solo alla relegazione
del cugino a Londra, ma anche alla sua partenza per Sidney o San
Francisco.
— È frivola e obliosa come tutte le donne, — pensava il vecchio
soldato. — Que’ suoi grandi ardori battaglieri sono sbolliti.
E non le sapeva grado della sua docilità. Era meno sicuro di aver
ragione dacchè nessuno gli dava torto.
Ella intanto ne pesava le parole, ne scrutava i silenzi, i gesti,
l’espressione della fisonomia, arrischiando di tratto in tratto con finta
ingenuità una frase, una domanda, come un generale che spinge
innanzi i suoi esploratori per esaminare il terreno.
— Se Federico deve lasciar l’Europa, — ella disse una mattina, —
suppongo che verrà prima a salutarci.
Bedeschi levò il capo con un movimento brusco. — Non so....
Forse.... Vedremo.... — E sentendo lo sguardo della nipote fisso
sopra di lui, si alzò da sedere e uscì dalla stanza.
La corrispondenza fra i due cugini durava non interrotta e non
vigilata. Federico tradiva spesso la sua impazienza, accusava la
Bice di non spiegar sufficiente energia per agevolargli il ritorno in
patria, dichiarava che assolutamente a Londra non ci poteva stare e
che avrebbe finito col fare un colpo di testa.... Poi, nella medesima
lettera, chiedeva scusa della sua petulanza e prometteva di seguire
a occhi chiusi i consigli della sua savia cuginetta, ch’egli si ricordava
in vestito da collegiale e che aveva giudizio da vendere a lui e a
molti altri meglio di lui.
E la savia cuginetta gli aveva scritto un giorno con gravità di esperta
diplomatica: — Un colpo di testa può anche esser necessario, ma
bisogna saper scegliere il momento di farlo. Il momento lo sceglierò
io.

II.

— Eccomi, — disse la Bice comparendo nel salotto ove si trovava lo

zio.
Egli gettò via il giornale L’Esercito che stava leggendo e si preparò a
darle una risciacquata di capo pel suo lungo ritardo. Ma l’aspetto
singolare in cui ella gli si presentava gli strappò invece un sorriso dal
labbro. E disse soltanto: — Finalmente!... E in quale arnese!
La ragazza aveva un lungo grembiale bianco che le scendeva dalle
ascelle ai piedi, le maniche del vestito rimboccate fino ai gomiti, le
mani e i polsi impiastricciati di farina, e teneva appunto le mani
aperte e le braccia larghe, discoste dai fianchi, per non insudiciarsi di
più. Aveva un po’ di farina anche sul viso e nei capelli.
— Eh, non ho terminato che adesso — ella rispose. — Sono in
tenuta di fatica.
— Vada a mutarsi dunque.... presto.
— Vado.... ma che cosa voleva, zio, che mi ha fatto chiamare?
È vero. Che cosa voleva? Non se lo rammentava neppur lui.... Ah sì,
voleva rimproverarla. E riprese: — Perder la giornata per fare un
dolce. Vergogna!
— Fare e rifare, caro zio.... Senza dubbio, la ricetta era sbagliata....
Si figuri che se non ci mettevo un bicchier di latte di più veniva fuori
qualcosa di duro come una palla di cannone....
— E ce l’hai aggiunto di tuo capo?
— Già.... La cuoca non vuole responsabilità. È un’impertinente. Sa
quel che ha detto? “Mi perdoni, ma io non intendo immischiarmi ne’
suoi pasticci.„
— Ha ragione.... Ma non forzerai neanche me a mangiarlo il tuo
pasticcio.
— Oh lo assaggerà almeno.... per poter suggerirmi le correzioni da
farsi domani.
— Domani?
— Ma scusi, non eravamo d’accordo? Quella d’oggi è una prova....
Domani poi che ci sono i veterani a pranzo.
La Bice chiamava così tre ufficiali in pensione, antichi commilitoni
dello zio, il quale li invitava a desinare un paio di volte all’anno.
— Per i veterani — interruppe il colonnello — manderemo a
prendere dall’offelliere un dolce che non sia duro come una palla di
cannone.
La ragazza fece un segno di protesta.
— E a proposito — ripigliò Bedeschi — che ghiribizzo è stato quello
di voler che invitassi i miei amici per domani e non per oggi?
— Volere? — disse la Bice con accento sommesso. — Ho pregato....
Mi pareva che la vigilia di Natale fosse meglio passarla in famiglia.
La fronte del colonnello si annuvolò. — Famiglia numerosa in verità
— egli borbottò fra i denti.
— Ma! — sospirò la Bice.
— Vatti a vestire, va, — soggiunse lo zio.
Ella non si moveva.
— Che c’è adesso?
— Nulla.... Pensavo.
— A che cosa?
— Pensavo a tanti anni fa.... l’anno prima ch’io andassi in collegio,
quando il Natale si festeggiò qui tutti uniti.... Che tavola allegra!
C’erano il mio babbo e la mia mamma, c’era la zia, e Vittorio e
Augusto, venuti in vacanza per una quindicina di giorni, e
Federico.... Noi due eravamo i più giovani.... Egli faceva mille
biricchinate e mi legò con la treccia alla spalliera della seggiola.... Oh
mi par ieri.... E ora gli uni son morti, gli altri dispersi pel mondo.
Si voltò commossa, con le pupille umide.
Lo zio, infastidito, le diede sulla voce. — Per carità, non mi far
piagnistei. I morti lasciamoli in pace, e quanto a quelli che sono
dispersi, due calcolo che siano con noi; il terzo, il tuo carissimo
Federico, è meglio dimenticarlo com’egli dimentica.
Ella fu in procinto di mettergli la mano sulla bocca per farlo tacere.
Ma si ricordò ch’era tutta infarinata e si trattenne in tempo,
sorridendo in mezzo alle lacrime: — Non le dica neanche per
ischerzo queste cose. Se Federico non ha ancora scritto, questo non
significa che abbia dimenticato.... Giurerei che la lettera è in viaggio.
Il colonnello fece una spallucciata. — Del resto, peggio per lui. A me
non importa proprio niente.
Balzò in piedi e ripetè alla nipote: — Vatti a vestire. A meno che oggi
non si debba rinunziare al pranzo....
La ragazza guardò l’orologio. — Pel pranzo ci vorrà un’oretta.... o
un’oretta e un quarto.... secondo il punto in cui sarà il dolce.
— Insomma, Bice, — saltò su lo zio aggrottando le ciglia, — ogni bel
gioco dura poco.... Vada e torni vestita entro venti minuti, e quando
torna, a qualunque punto sia il dolce, disponga perchè portino subito
in tavola.... Marsch.
— Oh, — esclamò il colonnello appena rimasto solo. — È
indispensabile di por ordine a questa faccenda. Colei con le sue
smorfiette ottiene sempre quello che vuole.
Il peggio si è ch’ella lo faceva diventar patetico, sentimentale, lui, il
colonnello Bedeschi! Non aveva dovuto rasciugarsi gli occhi, quella
sera stessa, nel guardare le fotografie di famiglia? Non era stato lì lì
per commoversi quando la Bice aveva evocato la memoria di quel
Natale lontano? Non si crucciava fuori di luogo e di modo perchè
quel caposcarico del figliuolo minore tardava a mandare gli auguri
per le feste? Non soffriva all’assenza di questo ragazzo più assai
che non volesse ammettere di soffrire? Non vedeva con un certo
sgomento avvicinarsi il tempo nel quale Federico avrebbe dovuto
andare di là dall’oceano? Non c’erano dei momenti in cui gli sarebbe
venuta una gran tentazione di richiamarlo?
No, così non poteva durare. Il colonnello aveva bisogno di ricuperar
la stoica impassibilità d’una volta, anche a costo di allontanar da sè
la nipote. Ell’aveva diciott’anni, era piacente, graziosa, possedeva un
quarantamila lire di suo, altre ventimila gliene avrebbe date lui, non
doveva esser difficile di trovarle un marito.... Trovarle marito, e poi
rimaner solo, con Battista, l’ordinanza, e coi veterani per commensali
nelle grandi solennità.... Che bella prospettiva! Tanto bella che il
colonnello, nell’eccesso della gioia, diede sulla tavola un pugno così
formidabile da far quasi cadere il lume. Indi se la prese col giornale
L’Esercito che gli parve indegno di avere nemmeno un associato;
stracciò in due pezzi il numero che aveva fra le mani e ne fece due
pallottole che scagliò a due angoli della stanza. Dopo le quali gesta
tirò fuori il suo cronometro per vedere se fossero trascorsi i venti
minuti ch’egli aveva assegnati alla Bice per la sua toilette.
— Venti minuti giusti, nè uno di più nè uno di meno, — disse la
giovinetta entrando proprio in quel punto. Ella vestiva un abito di
lana celeste con guarnizioni di peluche, portava al collo un filo di
corallo, e buccole pur di corallo agli orecchi. Nei folti e lucidi capelli
aveva intrecciato un nastrino di velluto rosso che ne faceva meglio
spiccare il colore castano scuro e dava risalto ai suoi occhi bruni e
vivaci. Del resto non aveva lineamenti regolarissimi, nè poteva dirsi
bella nello stretto senso della parola, ma la persona agile e svelta e
l’espressione della fisonomia dolce ed arguta ad un tempo la
rendevano preferibile a molte vantate bellezze.
— Sfido un’altra a far così presto, — ella continuò avanzandosi
verso lo zio, che, suo malgrado, era rimasto colpito dalla geniale
apparizione. Ma egli era armato contro le seduzioni e rispose in
tuono burbero: — Bene, bene.... E che necessità c’era di mettersi in
fronzoli?... Tutte civette, le donne....
— Oh zio, mi son messa il vestito buono e i coralli che mi ha
regalato lei il mese passato.... Dovevo lasciarli sempre chiusi in
cassetto?
— Non dico questo.... Se ci fosse qualcheduno a pranzo.... Domani,
per esempio....
— Oh, pegli estranei.... Se però esige che vada a mutarmi di
nuovo...?
— Sì, per non finirla più.... Hai dato gli ordini in cucina?
— No, veramente.... Volevo darli adesso....
Bedeschi mise un’esclamazione poco parlamentare e tirò con
violenza il campanello.
Si presentò Battista.
— Il pranzo è pronto? — chiese il colonnello con voce tuonante.
Il servo guardò la signorina.
— Non guardate la signorina, guardate me, e rispondete.
— Ma, — balbettò Battista. — Dev’esser pronto tutto.... tranne il
dolce.... che la cuoca dice che non sarà pronto mai....
— Gelosia di mestiere, — rimbeccò la Bice.
— Se tutto è pronto, tranne quello che non sarà pronto mai, —
ripigliò il colonnello, — scodellate la minestra immediatamente.
Battista voleva soggiungere qualcosa, ma la padroncina con un
gesto di rassegnazione lo pregò di tacere.
Di lì a poco, nel salotto da pranzo bene riscaldato ed illuminato, zio e
nipote sedevano a tavola l’uno di fronte all’altra e parevano entrambi
in poco felici disposizioni d’umore. Lo zio trovava da ridire su tutte le
pietanze, la nipote, d’ordinario chiacchierina e vivace, s’era
ammutolita ad un tratto, e in preda a una singolare inquietudine
s’agitava sulla sedia, tendeva l’orecchio ai più lievi rumori, e alzava
ogni tanto gli occhi verso la mostra d’un orologio.
La Bice arrossì come uno scolaro colto in fallo, e disse: —
Osservavo ch’è molto tardi.
— Bella scoperta! Di chi la colpa?
In quel momento si sentì una scampanellata alla porta di strada; la
Bice balzò fuori della stanza, e Battista, che quella sera serviva
peggio del solito, rovesciò una bottiglia di vino sulla tovaglia.
— Imbecille! — urlò il padrone. E avrebbe aggiunto chi sa quali altri
epiteti se non fosse stata la curiosità di saper chi era venuto.
— Andate di là, — egli ordinò al domestico che non se lo fece
ripetere due volte, — e tornate subito a dirmi chi è.
Ma Battista non tornò subito. Tornò invece la Bice con una strana
espressione nella fisonomia, e si fermò sulla soglia.
— Ebbene? Che cos’è successo? Siamo in un ospedale di pazzi? —
chiese il colonnello.
— Oh zio, — rispose la ragazza. — Se mi fa quei visacci non ho
coraggio....
— Finiamola.... Chi è venuto?
— È venuto.... un forastiero....
— Un forastiero.... Chi?....
La Bice esitava.
— Chi, in nome del cielo?
— Oh sa, faccio come nelle commedie, io.... Avanti, Federico.
E tirò a sè il battente dell’uscio, dietro a cui si trovava Federico in
persona.
Si ha un bell’esser corazzati contro le debolezze umane, si ha un bel
voler foggiarsi sul tipo inflessibile di Bruto primo e di Manlio, allorchè
un figliuolo che si credeva di non rivedere per un gran pezzo vi
compare dinanzi all’improvviso, e con uno sguardo più eloquente
d’ogni parola vi chiede perdono de’ suoi trascorsi e ridomanda la sua
parte di affetto e il suo posto al focolare domestico, è impossibile
non cedere al bisogno di spalancargli le braccia. Il tempo delle
riflessioni verrà, verrà forse il tempo di pentirsi dell’aver ceduto a
questo primo movimento; intanto il cuore, sia pur di sorpresa, riporta
una vittoria che non è mai senza conseguenze per l’avvenire.
Tutto ciò accadde al colonnello Bedeschi, il quale faceva inutili sforzi
per nascondere la propria emozione, e girando intorno a questo figlio
piovutogli dall’Inghilterra e divorandolo con gli occhi, tradiva la sua
sollecitudine con una sequela di domande: — Non sei mica malato,
eh? — Non hai mica patito freddo per viaggio? — Sei stanco? — Hai
ancora da pranzare?
E mentre Federico ch’era un florido giovinetto sui ventitrè anni gli
rispondeva che stava benissimo, che s’era rifocillato a Verona, ma
che nondimeno avrebbe preso volentieri una tazza di brodo, il
colonnello scoteva il braccio della Bice.... — Via, perchè non ti
muovi?... E dov’è quello stupido di Battista? O non c’è del brodo
caldo in cucina?
— Ce n’è, ce n’è.... Ecco Battista con la zuppiera. È provvisto alla
cena, alla camera, a tutto....
— Tu sapevi dunque?
— Naturalmente.
— E anche la servitù?
Battista evitava lo sguardo del padrone. Federico non alzava il naso
dal piatto. La Bice sola, imperterrita, affrontava il fuoco.
— Anche la servitù. Da questa mattina.... L’avevo detto io.
— Ma perchè tanti sotterfugi?
— Ecco.... — principiò Federico al quale sembrava poco
cavalleresco il non accorrere in aiuto a sua cugina.
Ma il padre lo interruppe. — Tu bada a mangiare. La Bice ha la
lingua sciolta.
— Oh, — ripigliò questa, — mi spiccio in due parole. Se Federico
scriveva a lei che non ne poteva più delle nebbie di Londra, che
provava un bisogno imperioso di riscaldarsi al sole d’Italia, di
rivedere la casa, la famiglia, insomma se le chiedeva il permesso, lei
non glielo avrebbe dato, e allora come si faceva a disubbidire?...
Invece di scrivere a lei, Federico scriveva a me.... Non era un
segreto la nostra corrispondenza....
— No, certo; però non mi sarei immaginato che ne usaste per
cospirare. Alle corte, quel permesso che forse non avrei dato io, l’hai
dato tu.
— Al momento opportuno ho incoraggiato Federico a perorar la sua
causa in persona. Lo assicuravo che suo padre era un uomo severo,
ma un cuore come ve ne son pochi....
— Basta, basta, — disse il colonnello. — È inutile dorare la pillola. —
Indi rivolgendosi al figliuolo: — E il mio amico Giraldi, il tuo
principale, è anche lui della congiura? Son sei o sette mesi che non
mi manda una riga.
Federico estrasse del taccuino una lettera e la porse al padre.
— Oh! — disse questo. — Son due lettere, una dentro dell’altra.
— Leggi e vedrai.
Giraldi scriveva ad Annibale Bedeschi lodandosi della condotta e
della intelligenza di Federico, ma soggiungendo che non gli pareva
uomo nato pel commercio, e che, secondo lui, era molto meglio
lasciargli studiar l’arte per la quale mostrava disposizioni singolari. In
prova di che inchiudeva un biglietto del celebre Whitty, uno dei primi
pittori di Londra, che aveva visto i disegni del giovine e ne traeva i
più lieti pronostici per l’avvenire.
Il colonnello diede un’occhiata al biglietto in questione. — È in
inglese! — egli esclamò. — O che che cosa devo capirci io?
Federico si offerse di tradurlo. Ma la Bice propose di rimetter le
spiegazioni al domani. Erano tutti stanchi, e Federico in particolare
cascava dal sonno.
— È vero, — assentì il colonnello. — Federico dovrebbe andarsene
a letto.
A questo punto la Bice si picchiò la fronte con la mano. — E il mio
dolce? Battista, fate il piacere di domandarne conto alla cuoca.
Il cugino mise un’esclamazione ammirativa. — Anche di pasticceria
te ne intendi?
— Un poco.
— Uhm! — fece il colonnello.
Battista rientrò in salotto con aria contrita, e depose davanti al
padrone un piatto che conteneva un oggetto informe.
— È questo il tuo dolce? — chiese ironicamente lo zio dopo alcuni
vani tentativi di fenderne la crosta col coltello.
La Bice, mortificata, non riconosceva più l’opera sua. — Così me lo
hanno ridotto?
Federico non potè trattenere una sonora risata.
— Hai torto di ridere, — disse la giovinetta. — Quella, vedi, è tutta
malizia della cuoca, invidiosa de’ miei trionfi. Un’altra volta....
— Non c’è altra volta che tenga, — protestò il colonnello. — Basta
una, ce n’è d’avanzo.
La Bice si strinse nelle spalle. — Il mio dolce avrà servito a ogni
modo a far ritardare il pranzo. Se la corsa fosse arrivata in orario,
Federico avrebbe desinato con noi, anzichè trovarci alle frutta.... E
adesso....
— O che c’è ancora?... Non volevi che tuo cugino andasse a
riposarsi?
— Sì, ma poichè rimane un sorso di vino nei bicchieri faccio un
brindisi ai due assenti Vittorio e Augusto.
— Con tutto il cuore, — risposero a una voce padre e figliuolo.
— Agli assenti e al reduce, — ella soggiunse.
— Sia pure.... Anche al reduce, — ripetè il colonnello avvicinando il
suo bicchiere a quello di Federico. — Abbiamo però sempre dei
conti da regolare.

· · · · · · · · · · · · · · · ·

Quando Federico si mosse per salire nella sua camera, la Bice lo

accompagnò fino sul pianerottolo. Egli non aveva parole abbastanza
per ringraziarla, per esaltare il suo spirito, la sua bravura.
— Non facciamoci illusioni — ella disse. — Non cantiamo vittoria
troppo presto.
— Con te, mia cara, si vinceranno tutte le battaglie, — replicò il
cugino. E dopo una breve pausa, abbassando la voce e
avvolgendola d’uno sguardo ch’esprimeva il più sincero entusiasmo:
— Sai che ho fatto un’altra grande scoperta?
La Bice abbassò involontariamente gli occhi. — Quale?
— Che sei diventata proprio bella.... ma proprio.... non è già un
complimento.
— Pazzo che sei! — disse la ragazza imporporandosi in viso. —
Buona notte, buona notte. — El o piantò lì col lume in mano,
incantato a guardarla.

· · · · · · · · · · · · · · · ·

Come si accomodassero le faccende il dì appresso, che

conseguenze avesse nell’avvenire la grande scoperta di Federico, a
che risultato approdasse la visibile simpatia de’ due cugini, son tutte
cose che non si possono saper subito.... Al Natale prossimo.... forse.
 LA ZIA TERESA.

Quella sera, quando s’udì la scampanellata del postino, in casa

dell’avvocato Ettore Gualtieri avevano appena finito di desinare. La
cameriera entrò in salotto portando due giornali pel padrone e una
grossa lettera coperta di francobolli per la signorina Amelia.
La signorina Amelia, una leggiadra giovinetta di forse diciott’anni,
divenne rossa ed esclamò: — È della zia Teresa.
E agitando la lettera con aria trionfale soggiunse: — Scommetto che
qui c’è la fotografia. Era tempo.
Con un oh, oh di curiosità tutti quanti si strinsero intorno all’Amelia.
Erano in quattro, l’avvocato Ettore e la signora Luisa sua moglie, la
Carolina, una ragazza in quell’età critica nella quale è arrischiato
ogni pronostico sulla bellezza femminile, e Amedeo, un fanciullo
sgarbato come sogliono essere i maschi dagli otto ai quindici anni.
— Bada che voglio i francobolli — gridò appunto Amedeo con la sua
voce di pentola fessa.
— E io il monogramma — disse la Carolina.
L’Amelia fece un gesto d’impazienza. — Dio, che noiosi! Avrete i
francobolli, avrete il monogramma, ma non istatemi addosso così.
L’avvocato allontanò col braccio i due importuni e diede alla sua
figliuola maggiore un temperino perch’ell’aprisse la busta senza
stracciarla.
Bisogna notare che, dal signor Ettore in fuori, nessuno dei presenti
aveva conosciuto questa zia Teresa. In primo luogo, dei giovani ella
non era zia ma prozia; aveva cioè sposato molto tempo addietro uno
zio dell’avvocato, un Gualtieri anch’esso, dimorante a Nuova York fin
dal 1849 e arricchitosi colà negli affari. Al momento del matrimonio il
signor Temistocle (l’uomo si chiamava così) aveva
quarantacinqu’anni ed ella ne aveva venti, nè alcuno credette ch’ella
lo prendesse per inclinazione. Comunque sia, questo signore, tanto
più vecchio della moglie, s’era conservato vispo ed arzillo e veniva
ogni due anni in Italia; ella invece tra per le cure da prestarsi al
padre che l’aveva seguita in America, tra per gli acciacchi di cui si
lagnava, non aveva più ripassato l’Oceano.
Erano queste le ragioni ch’ell’adduceva scrivendo all’Amelia, ma il
marito, ne’ suoi viaggi in Europa, affermava che la ragione vera era
la pigrizia, era la paura del mare.
— La salute — egli soleva ripetere — l’ha buonissima, e ingrassa di
giorno in giorno. Anzi, inter nos, questo potrebb’essere un altro dei
motivi pei quali le ripugna di tornare dove c’è tanta gente che se la
ricorda giovine e bella.... Donne, sempre donne.... Già, ne avete la
prova.... ha perfino scrupolo di farsi fare il ritratto per mandarvelo.
Alla lunga, come si vede, lo scrupolo ella lo aveva vinto, e la lettera
giunta quella sera all’Amelia conteneva realmente la sospirata
fotografia.
Bisogna convenire che la prima impressione fu tale da richiamare
alla memoria le parole poco galanti del signor Temistocle. La zia
Teresa aveva l’aspetto d’una donna attempata, più florida del
necessario, senza studio d’eleganza nel vestito ch’era liscio, d’una
sola tinta scura e chiuso fino al collo. Nei capelli spartiti sulle tempie
e ravviati dietro alle orecchie era appuntato un velo nero; la mano
sinistra non si vedeva, la destra, appoggiata sulla spalliera della
poltrona, si protendeva troppo innanzi e appariva di proporzioni
esagerate. Gli occhi ch’erano stati bellissimi, che si capiva dover
essere belli tuttora, erano guastati dalla fotografia mancante
assolutamente di nitidezza e di rilievo.
Vi fu un breve silenzio durante il quale un osservatore attento
avrebbe potuto notare nel volto della signora Luisa un risolino di
trionfo che contrastava con l’aria malsoddisfatta degli altri e
specialmente dell’avvocato. — È questa la zia Teresa? — parevano
domandare i ragazzi. E l’avvocato: — È proprio lei?
Amedeo ruppe il ghiaccio. — Sapete a chi somiglia?... Alla signora
Venosti.
Il babbo gli slanciò uno sguardo fulmineo. — Sciocco!
Anche l’Amelia protestò con gran vivacità.
Ma la signora Luisa venne in aiuto del figliuolo. — Amedeo non ha
tutti i torti. La ricorda....
— No, mamma, no, — rimbeccò l’Amelia che non poteva tollerare
questi paragoni tra una zia dilettissima e una conoscente ridicola da
lei messa in canzonatura infinite volte.
— Si fa presto a dir no, — insistè la signora Luisa. — È un fatto.
Il signor Ettore perdette la pazienza. — Insomma vorrei sapere dove
la si trova questa famosa rassomiglianza....
— Nella bocca, per esempio....
— Oh santo cielo. Nella bocca?... Se la Venosti non ha quasi più
denti....
— E in questo ritratto, con tua licenza, la bocca è chiusa e non
possiamo sapere se i denti ci siano o non ci siano. E poi il taglio
della bocca non ha nulla a che fare coi denti....
— Via, mamma, — ripigliò l’Amelia, — la Venosti ha più di
sessant’anni.
— E credi forse che tua zia sia una bambina?... I suoi cinquanta
deve bene averli....
L’avvocato fece un energico segno negativo col capo. — Nemmen
per sogno.
— O quanti allora?
— È un conto semplice. È nata nel 1843 e siamo nel 1888.
— Da ottantotto a levar quarantatrè rimangono quarantacinque, —
esclamò Amedeo per mostrar la sua perizia nell’aritmetica.
— Precisamente quarantacinque, — ripetè il signor Ettore.
— Più quelli della balia, — soggiunse sghignazzando la moglie.
— È una bella ostinazione, — replicò l’avvocato. — Vuoi un’altra
prova? La Teresa si sposò nell’agosto 1863, venticinque anni fa, nè
più nè meno.... E aveva compiuto i vent’anni in quel mese stesso.
— Sarà, — disse la signora Luisa con quella riluttanza che hanno le
donne a darsi per vinte, soprattutto in certe questioni. — A ogni
modo se non sono che quarantacinqu’anni non gliene faccio le mie
congratulazioni.... Ne mostra molti di più.
Frattanto l’Amelia, che aveva scorso rapidamente la lettera della zia,
ne lesse una mezza pagina ad alta voce: “È la prima volta che vado
dal fotografo dacchè ho lasciato l’Europa. E ci andai per contentarti.
Desidero in compenso di aver le fotografie rinnovate di tutti voi altri.
Ho la tua, quelle di tua sorella e di tuo fratello, ma le ultime
rimontano al 1885 e ritengo che ne avrete di più recenti. Non ho poi
quelle della tua mamma e del tuo babbo, e mi sarebbe così caro di
averle.... Il tuo babbo mi trova molto cambiata, non è vero? Eh, il
tempo passa per tutti, e per noi donne passa più presto che pegli
uomini.„
— Bisogna tornar da Vianelli, — disse l’Amelia ripiegando il foglio.
— Torniamoci addirittura domani. — propose la Carolina.
— Oh, — replicò la madre, — ci andrete voi. Io farò tirar qualche
altra copia dei ritratti del 1885, quelli che ci siam fatti, il babbo ed io,
pochi mesi dopo dei vostri.
E rivolgendosi al marito: — Mi sembra che anche tu potresti
spicciarti allo stesso modo.
L’avvocato sorrise. — No, io voglio esser sincero. Non voglio farmi
passar per più giovine di quello che sono. È giusto che la zia Teresa
trovi cambiato me come io trovo cambiata lei.
Questa dichiarazione in cui c’era una punta d’ironia crebbe le
disposizioni irascibili della signora Luisa. — Io non sono tenuta ad
aver tanti scrupoli, ella disse con piglio acre. — La zia Teresa non mi
ha conosciuta e non può quindi trovarmi cambiata. Già non crederei
d’esser così cambiata in tre anni.
La signora Luisa, sebben rasentasse la quarantina, aveva ancora le
sue pretese.
Il marito non le diede la soddisfazione di rilevare le sue parole, ma si
mise a sgridare Amedeo che, uscito un momento dalla stanza, vi
rientrava con malagrazia rovesciando una seggiola sul suo
passaggio.
Avvezzo ai rimproveri paterni, il ragazzo si limitò a rialzare la
seggiola e posò un grosso album sulla tavola. — Me li lasci levare
questi francobolli? — egli chiese all’Amelia stendendo la mano verso
la busta.
— Aspetta un momento.... Non scappano mica....
— Giacchè ho qui l’album....
La Carolina ricordò timidamente che doveva avere il monogramma.
— Lo so, lo so, l’ho già sentito.... Son gusti incomprensibili.... Ne
avete non so quanti di questi francobolli di Nuova York, di questi
monogrammi della zia Teresa.... Giurerei che non avete altro nei
vostri splendidissimi album....
— Oh sì! Io ho quarantotto francobolli tutti diversi....
— E io ventitrè monogrammi.... tutti magnifici....
— Figuriamoci....
Mentre i figliuoli si bisticciavano, la signora Luisa s’era rimessa a
guardare la fotografia, e, siccome ell’era di quelle che nelle dispute
non la finirebbero mai, riattaccò il discorso al punto di prima.
— Che col tempo le linee della fisonomia e della persona si
modifichino, è troppo naturale — ella disse riconsegnando il ritratto
all’Amelia; — ma altro è modificarsi, altro è trasformarsi.... E a me
non entrerà in mente che questa donna sia stata bella.
Gualtieri si strinse nelle spalle. — Ce ne furono poche di belle come
lei.
— Basta sentir lo zio Temistocle, — notò l’Amelia.
— Oh, lui, s’intende, — rispose la madre. — Se l’ha sposata senza
un soldo è segno che a lui pareva bella....
— Pareva?... Era bella, era bella.... con o senza il tuo permesso, —
ribattè infastidito l’avvocato.
— Non riscaldarti il sangue.... È evidente che tutti e due, zio e
nipote, la trovavate la Venere dei Medici.... Però una Venere che
preferì chi poteva vestirla di porpora e di velluto.
La signora Luisa non aveva ancora terminata la frase imprudente
ch’ell’era già pentita di essersela lasciata sfuggire. Ma ormai era
troppo tardi.
Una fiamma passò negli occhi di Ettore Gualtieri. Pur si contenne e
con una voce che l’emozione rendeva più penetrante, — Luisa, —
egli disse, — a te non è lecito ignorare per qual ragione la Teresa
Rosnati abbia sposato mio zio che aveva più del doppio della sua
età e ch’ella non amava. Che se tu lo hai dimenticato, stimo
opportuno di ricordartelo, anche perchè i nostri figliuoli, qui presenti,
non giudichino male una zia che non hanno mai vista, che forse non
vedranno mai, ma dalla quale non hanno ricevuto che gentilezze....
Oh non è una storia lunga.... La Teresa era le mille miglia lontana
dall’idea di quel matrimonio quando suo padre, rovinato da cattive
speculazioni, si trovò in procinto di fallire. Il suo maggior creditore
era Temistocle Gualtieri, stabilito da un pezzo in America, ma giunto
allora in Europa per uno de’ suoi viaggi d’affari. Corso a Venezia per
questo minacciato fallimento, egli vide la ragazza, se ne invaghì e ne
chiese la mano. Pur d’ottenerla, non solo egli accondiscendeva ad
annullare il debito che il Rosnati aveva verso di lui e lo aiutava a
liquidar onorevolmente la casa, ma gli offriva un posto lucroso nel
suo banco a Nuova York. D’altra parte, egli diceva chiaro e tondo